1 Copyright 2017 Functional Movement Systems Version 2 SCREENING & ASSESSING BREATHING: A MULTIDIMENSIONAL APPROACH
SCREENING & ASSESSING BREATHING: A MULTIDIMENSIONAL APPROACH
Feb 13, 2023
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SCREENING & ASSESSING BREATHING: A MULTIDIMENSIONAL APPROACH
2Copyright 2017 Functional Movement Systems
The information contained herein is not intended to be a substitute for professional medical advice, diagnosis or treatment in any manner. Always seek the advice of your physician or other qualified health provider with any questions
you may have regarding any medical condition or before engaging in any physical fitness plan. All rights reserved. No part of this manual may be reproduced or transmitted in any form whatsoever without written permission from the author or
publisher, with the exception of the inclusion of brief quotations in articles or reviews. Copyright 2017 Functional Movement Systems .and Rosalba Courtney.
1Copyright 2017 Functional Movement Systems
Table Of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Functional vs Dysfunctional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Functions of Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Introduction The presence of dysfunctional breathing affects overall health and musculoskeletal system performance. It contributes to many symptoms and functional disturbances, including those affecting the musculoskeletal system. It can contribute to decreased pain thresholds, impaired motor control and balance, and subsequent movement dysfunction. Each of these impairments adversely affects performance in fitness and rehabilitation. Recent research has exposed that breathing dysfunction is multi-dimensional in nature and includes three (3) primary categories or dimensions of dysfunction, which are the biochemical dimension, the biomechanical dimension, and the psychophysiological / symptomatic dimension.
Due to the complex and multi-dimensional nature of dysfunctional breathing, no single test or screening tool can reliably stand alone to identify the client or patient with dysfunctional breathing. Proper evaluation of dysfunctional breathing needs to be comprehensive and consider all 3 key dimensions and consider causes and contributing factors.
This course is designed for the fitness and healthcare professional to provide the background and details that support functional and dysfunctional breathing. It introduces Dr. Courtney’s multi-dimensional "EAARS" model of breathing function and a novel "Breathing Screen." Several tools to assess and test for breathing dysfunction are also provided. Additionally, we introduce a breathing re-training exercise approach, grounded in the neurodevelopmental progression that can be applied in the fitness and rehabilitation settings. The course is organized into six (6) learning units subdivided into 33 chapters and includes hands-on assessment and treatment demonstrations in a case-study format.
4Copyright 2017 Functional Movement Systems
Functional vs Dysfunctional Breathing The term "dysfunctional breathing" can be somewhat vague as people have used the term to reference a range
of breathing behaviors and symptoms, including the following:
People may categorize dysfunction as:
Hyperventilation and low CO2
Unexplained breathing discomfort
Ask yourself: “What is functional breathing?” "Functional breathing is breathing that efficiently and appropriately performs primary and secondary functions"
EAARS Functional breathing has the following characteristics:
1. Efficient
2. Adaptive
3. Appropriate
4. Responsive
5. Supportive
Functions of Breathing PRIMARY FUNCTIONS OF BREATHING
1. Biomechanical
a. Refers to the actions of the neuromuscular respiratory pump
b. Creates changes in the intra-abdominal and intra-thoracic pressure that drive the movement of air,
lymph and blood
2. Biochemical
a. Refers to its effect on blood gases and body chemistry
SECONDARY FUNCTIONS OF BREATHING Breathing plays a very important role in non-respiratory functions such as the following:
Self regulation of mental and emotional states
Speech and vocalization
6Copyright 2017 Functional Movement Systems
Multidimensional Model Recent research has exposed that breathing dysfunction is multi-dimensional in nature and includes 3 primary categories of dysfunction: biochemical ( CO2, pH ), biomechanical (patterns, ribcage movement, respiratory muscles), and the psychophysiological dimension. No single test or screening tool can reliably stand alone to identify the client or patient with dysfunctional breathing. Proper evaluation of dysfunctional breathing needs to be comprehensive and consider all 3 key dimensions as well as causes and contributing factors. Single tests can tend to give information about one dimension while overlooking others.
More severe cases of dysfunctional breathing show an overlap of symptoms in each of the 3 domains (see
image below).
Biochemical Dimension The biochemical dimension refers to disturbances in oxygen, carbon dioxide and pH. Hyperventilation is
the most common disturbance in the biochemical dimension. Hyperventilation means breathing in excess
of metabolic requirements with subsequent depletion of CO2. The presence of hyperventilation occurs
when breathing in excess of metabolic requirements leads to the depletion of CO2. People with chronic
hyperventilation can have abnormal breathing control and inaccurate breathing perception. They tend to
abnormally increase rather than decrease ventilation levels when their carbon dioxide levels decrease. This
creates a flywheel effect that perpetuates hyperventilation and hypocapnia. Hyperventilators often feel like
they are not breathing enough even though they are over-breathing which also perpetuates hyperventilation.
One common characteristic of hyperventilators is that instead of controlling breathing, they tend to amplify
the symptoms of hyperventilation and over breathe. This effect can alter an individual’s perception of what is
normal breathing.
8Copyright 2017 Functional Movement Systems
Biomechanical Dimension Breathing Pattern Disorders
1. Thoracic/upper rib cage
2. Excessively irregular breathing
Thoracic Breathing Patterns Characterized by rate volume, rhythm, regularity, timing and dominance
Lower Rib Cage Abdominal
Upper Rib Cage Thoracic
Direction of movement: 1. Normal - Expansion, outwards motion during inhale
2. Paradoxical - Contraction, inwards motion during inhale
Normal Abnormal
THORACIC BREATHING
Supports diaphragm function
Recruited too early
Tension patterns - posterior > anterior (hamstring) Stereotypical Posture of Inhalation Schema
Hyperboloids with rib flaring
Tension at TL Junction
Tension patterns - Anterior > Posterior
1. Reduced ability to dynamically & accurately regulate intra-abdominal pressure
a. Poor motor control
b. Poor spinal support
2. Muscle Imbalance - (neck, shoulder, girdle, abdominals, spine and pelvis)
a. Neck pain
b. Back pain
c. Pelvic pain
11Copyright 2017 Functional Movement Systems
Psychophysiological Dimension It is important to understand that mental and emotional states have a large impact on breathing function and breathing symptoms. The way a person breathes -- both consciously and unconsciously -- can affect the function of the brain and nervous system and mental and emotional states.
The psychophysiological dimension influences ventilatory drive and breathing pattern. It impacts breathing control and can perpetuate dysfunction in the biochemical and biomechanical dimensions.
12Copyright 2017 Functional Movement Systems
Breathing Assessment Basic Principles
For each domain, evaluate at rest and under challenge.
Evaluate breathing in response to and as part of secondary (breathing related function of concern e.g
muscular-skeletal).
Breathing Considerations During a Musculo-Skeletal Exam Breath holding during motor tasks can be a sign of motor control dysfunction
Clients may breath-hold in anticipation of pain or movement and can be a conditioned response that
persists even after pain is gone
Flexion/Extension restrictions in relation to inhalation/exhalation dysfunctions: Someone with an
extension restriction may also have an inhalation restriction. Someone with a flexion restriction may
also have an exhalation restriction
Breathing restrictions/dysfunctions may also cause restrictions in shoulder mobility, dysfunctional
rolling patterns, and balance impairments
Order of Assessment 1. Perform Top Tier SFMA
2. Biochemical Assessment
a. Observation & Testing
b. Breath Holds
3. Biomechanical Assessment
a. Hi-Lo Assessment
b. MARM Assessment
4. Psychophysiological Dimension
a. This is indicated when there are large numbers of symptoms on SEBQ and NQ. Also look for positive
response to questions asking about stress, tension and anxiety in these questionnaires
13Copyright 2017 Functional Movement Systems
Multi-Segmental Flexion
SFMA SCORING
Single-Leg Stance
Multi-Segmental Rotation
Multi-Segmental Extension
Upper Extremity Pattern 1(MRE)
14Copyright 2017 Functional Movement Systems
Name: Date: Total Score: Cervical Flexion Painful Can’t touch Sternum to Chin Excessive effort and/or lack of motor control Cervical Extension Painful Not within 10 degrees of parallel Excessive effort and/or lack of motor control Cervical Rotation Painful Right Painful Left Right Left Nose not in line with mid-clavicle Right Left Excessive effort and/or appreciable asymmetry or lack of motor control Pattern #1 – MRE Painful Right Painful Left Right Left Does not reach inferior angle of scapula Right Left Excessive effort and/or appreciable asymmetry or lack of motor control Pattern #2 – LRF Painful Right Painful Left Right Left Does not reach spine of scapula Right Left Excessive effort and/or appreciable asymmetry or lack of motor control Multi-Segmental Flexion Painful Cannot touch toes Sacral angle <70 degrees Non-uniform spinal curve Lack of posterior weight shift Excessive effort and/or appreciable asymmetry or lack of motor control Multi-Segmental Extension Painful UE does not achieve or maintain 170 ASIS does not clear toes Spine of scapula does not clear heels Non-Uniform spinal curve Excessive effort and/or lack motor control Multi-Segmental Rotation Painful Right Painful Left Right Left Pelvis Rotation <50 degrees Right Left Shoulders rotation <50 degrees Right Left Spine/pelvic deviation Right Left Excessive Knee flexion Right Left Excessive effort and/or lack of symmetry or motor control Single Leg Stance Painful Right Painful Left Right Left Eyes open <10 seconds Right Left Eyes closed < 10 seconds Right Left Loss of Height Right Left Excessive effort or lack of symmetry or motor control Overhead Deep Squat Painful Loss of UE start position Tibia and Torso are not parallel or better Thighs do not break parallel Loss of sagittal plane alignment: Right____ Left _____ Excessive effort, weight shift, or motor control
THE SELECTIVE FUNCTIONAL MOVEMENT ASSESSMENT
15Copyright 2017 Functional Movement Systems
BIOMECHANICAL TESTING 2 stages in testing:
1. Observation
b. Look for hypertonicity in scalenes, SCM, traps, thoracolumbar region
c. Look at movement of shoulders, ribcage, umbilicus in 4 positions
2. Test/measurement
Observation in standing 1. Side on
a. May see forward head, tension in body front vs back
2. Front
a. Signs of hyperactivity in anterior neck, overdeveloped trapezius, dip above clavicle, may see chest
heaving
Assessment of biomechanical dimension in a seated position 1. Observe for muscle hypertonicity and chest or shoulder movement during the breath
2. Can also observe while speaking, looking for gasping, choppy sentences, or speeding up and slowing
down
Behind 1. Look for hypertonicity or over-development of the upper traps
Assessment of biomechanical dimension in a supine position 1. Look for direction of umbilicus movement
2. Look for rib flaring or hollowing out of the stomach (both dysfunctional if present)
3. If you are not sure if this is happening, ask the patient to shallowly breathe gently and slowly into your
hand placed on the stomach to assess for inactivity or hollowing out of the stomach during inhale
Assessment of biomechanical dimension in a prone position 1. Look for direction of umbilicus movement
2. Look for rib flaring or hollowing out of the stomach (both dysfunctional if present)
3. If you are not sure if this is happening, ask the patient to shallowly breathe gently and slowly into your
hand placed on the stomach to assess for inactivity or hollowing out of the stomach during inhale
16Copyright 2017 Functional Movement Systems
Hi-Lo Test This test is performed in the sitting position. The clinician stands or kneels at the front and slightly to the side of
the patient and places one hand on their sternum and one hand on their upper abdomen to determine whether
thoracic or abdominal motion is dominant during breathing. The clinician will demonstrate on themselves
where the palpation points will be, and in the case when a female subject is not comfortable with a male
clinician performing the test, a female clinician will be made available. They will also check for paradoxical
breathing by seeing if the abdomen moves in a direction opposite to the thorax during breathing; this is evident
during inhalation if the abdomen moves toward the spine, and during exhalation, if the abdomen moves in an
outward direction. Test will assess for up to five (5) breath cycles.
Demonstration Assessment
MARM Assessment The Manual Assessment of Respiratory Motion (MARM) was originally developed by Dr. Jan van Dixhoorn. It
is used to assess and quantify breathing patterns, and in particular, the distribution of breathing motion
between the upper and lower parts of the rib cage and abdomen under various conditions. Research has
shown that it is a reliable assessment tool in the hands of trained practitioners (Courtney and Dixhoorn
2009). It does require practice, but once the skills of using this technique and recording findings are acquired,
it is a practical and quick technique.
Hand Position
INSTRUCTIONS
1. Sit behind the subject and place both your hands on the lower lateral rib cage so that your whole hand
rests firmly and comfortably and does not restrict breathing motion.
2. Your thumbs should be approximately parallel to the spine, pointing vertically and your hand
comfortably open with fingers spread so that the little finger approaches a horizontal orientation.
3. Note that the 4th and 5th finger reach below the lower ribs and can feel abdominal expansion.
4. You will make an assessment of the extent of how overall vertical motion of your hands feel relative to
the overall lateral motion.
5. Also decide if the motion is predominantly upper rib cage, lower rib cage/abdomen correlatively
balanced.
Use this information to determine the relative distance from the horizontal line of the upper and lower lines of the MARM diagram. The upper line will be further from the horizontal and closer to the top if there is more vertical and upper ribcage motion. The lower line will be further from the horizontal and closer to the bottom if there is more lateral and lower rib cage/abdomen motion.
6. Finally get a sense of the overall magnitude and freedom of rib cage motion. Place lines further apart to
represent greater overall motion and closer for less motion
18Copyright 2017 Functional Movement Systems
Recording MARM
Draw Upper Line (Line A) Represents upper rib cage and vertical breathing motion
Draw Lower line (Line B) Represents lower rib cage and lateral breathing motion
90 degree line (Line C) This is a reference line only
180
90
0
180
90
0
A
B
C
19Copyright 2017 Functional Movement Systems
The Nijmegen Questionnaire The Nijmegen Questionnaire (NQ) gives a broad view of symptoms associated with dysfunctional breathing
patterns. The Nijmegen Questionnaire was introduced over 30 years ago as a screening tool to detect patients
with hyperventilation complaints who could benefit from breathing training.
Never
0
Rare
1
Sometimes
2
Often
3
Feelings of Anxiety
Scoring the Nijmegen Questionnaire Add all number for a total score. 20 indicates Dysfunctional Breathing.
20Copyright 2017 Functional Movement Systems
The SEBQ The Self Evaluation Breathing Questionnaire (SEBQ) measures a number of different types or qualities of breathing discomfort. It also contains questions about dysfunctional breathing behaviors such as mouth breathing. It was developed by Dr. Rosalba Courtney (Courtney, Greenwood 2009) to represent the broad range of symptoms reported to be found in individual with dysfunctional breathing. Research has shown it to be a reliable instrument for testing and retesting. This makes this questionnaire useful for gauging the effectiveness of breathing training.
The Self Evaluation Breathing Questionnaire 0 1 2 3 I get easily breathless out of proportion to my fitness
I notice myself breathing shallowly
I get short of breath reading and talking
I notice myself sighing
I notice myself yawning
I feel I cannot take a deep or satisfying breath
I notice that I am breathing irregularly
My breathing feels stuck or restricted
My ribcage feels tight and can’t expand
I notice myself breathing quickly
I get breathless when I am anxious
I find myself holding my breath
I feel breathless in association with other physical symptoms
I have trouble coordinating my breathing when speaking
I can’t catch my breath
I feel that the air is stuffy, as if not enough air in the room
I get breathless even when resting
My breath feels like it does not go in all the way
My breath feels like it does not go out all the way
My breathing is heavy
My breathing requires work
My breathing requires effort
I breathe through my mouth at night while I sleep
(0) never/not true at all (1) occasionally/a bit true
Scoring the SEBQ To Score the SEBQ just add the numbers Individuals with scores >= 20 on the Nijmegen on average score >=11 on the SEBQ.
(2) frequently-mostly true (3) very frequently/very true
21Copyright 2017 Functional Movement Systems
Breathing Screen The breathing screen was introduced to help identify if people do/do not have a breathing dysfunction. From internal research, we found that breath hold time and 4-Questions have a sensitivity of .89 for ruling out breathing dysfunction. If you pass the screen, we are 89% sure you don’t have a breathing problem (Kiesel, Rhodes, Mueller, Waninger, Butler, 2016).
BREATH HOLD TIME Breath holding time is shorter in individuals who have increased ventilatory drive or lowered breathlessness thresholds due to psychophysiological, biomechanical or biochemical factors. Short breath holding time can indicate dysfunction in any of these 3 dimensions.
Breath holding time can be tested in 2 ways:
1. After a normal exhale (also know as functional residual capacity)
2. After a full inhale (also known as total lung capacity)
BREATH HOLDING AT FUNCTIONAL RESIDUAL CAPACITY (FRC) FRC refers to the volume of air left in the lungs after a normal, passive exhalation. Breath holding at FRC means holding the breath after a normal relaxed exhalation. Breath holding times help gauge an understanding of all dimensions of breathing because the biomechanical and psychophysiological
dimensions can also affect outcome of breath holding times.
Instructions 1. Have the individual breathe in, breathe out naturally. At the end of the exhale, ask them to hold their
breath by plugging their nose.
2. Tell them to hold their breath until they feel a clear desire to breathe or experience involuntary muscle
activity from the diaphragm or other breathing muscles.
3. Start a timer as soon as the individual holds their breath, and stop when they release their nose or you
see the first sign of muscle activity.
Tips for testing Look for the first sign to breathe. (Normally muscle activity in the stomach or neck)
Interpretation If time is less than 25 seconds, suspect possible dysfunctional breathing
22Copyright 2017 Functional Movement Systems
Breathing Screen BREATH HOLDING AT TOTAL LUNG CAPACITY (TLC) TLC refers to the total volume of air in the lungs at maximal inspiration.
Instructions 1. Have the individual breathe in and then breathe out, then take a deep breath in (maximum inhalation) and hold
their breath by plugging their…
2Copyright 2017 Functional Movement Systems
The information contained herein is not intended to be a substitute for professional medical advice, diagnosis or treatment in any manner. Always seek the advice of your physician or other qualified health provider with any questions
you may have regarding any medical condition or before engaging in any physical fitness plan. All rights reserved. No part of this manual may be reproduced or transmitted in any form whatsoever without written permission from the author or
publisher, with the exception of the inclusion of brief quotations in articles or reviews. Copyright 2017 Functional Movement Systems .and Rosalba Courtney.
1Copyright 2017 Functional Movement Systems
Table Of Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Functional vs Dysfunctional . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Functions of Breathing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Introduction The presence of dysfunctional breathing affects overall health and musculoskeletal system performance. It contributes to many symptoms and functional disturbances, including those affecting the musculoskeletal system. It can contribute to decreased pain thresholds, impaired motor control and balance, and subsequent movement dysfunction. Each of these impairments adversely affects performance in fitness and rehabilitation. Recent research has exposed that breathing dysfunction is multi-dimensional in nature and includes three (3) primary categories or dimensions of dysfunction, which are the biochemical dimension, the biomechanical dimension, and the psychophysiological / symptomatic dimension.
Due to the complex and multi-dimensional nature of dysfunctional breathing, no single test or screening tool can reliably stand alone to identify the client or patient with dysfunctional breathing. Proper evaluation of dysfunctional breathing needs to be comprehensive and consider all 3 key dimensions and consider causes and contributing factors.
This course is designed for the fitness and healthcare professional to provide the background and details that support functional and dysfunctional breathing. It introduces Dr. Courtney’s multi-dimensional "EAARS" model of breathing function and a novel "Breathing Screen." Several tools to assess and test for breathing dysfunction are also provided. Additionally, we introduce a breathing re-training exercise approach, grounded in the neurodevelopmental progression that can be applied in the fitness and rehabilitation settings. The course is organized into six (6) learning units subdivided into 33 chapters and includes hands-on assessment and treatment demonstrations in a case-study format.
4Copyright 2017 Functional Movement Systems
Functional vs Dysfunctional Breathing The term "dysfunctional breathing" can be somewhat vague as people have used the term to reference a range
of breathing behaviors and symptoms, including the following:
People may categorize dysfunction as:
Hyperventilation and low CO2
Unexplained breathing discomfort
Ask yourself: “What is functional breathing?” "Functional breathing is breathing that efficiently and appropriately performs primary and secondary functions"
EAARS Functional breathing has the following characteristics:
1. Efficient
2. Adaptive
3. Appropriate
4. Responsive
5. Supportive
Functions of Breathing PRIMARY FUNCTIONS OF BREATHING
1. Biomechanical
a. Refers to the actions of the neuromuscular respiratory pump
b. Creates changes in the intra-abdominal and intra-thoracic pressure that drive the movement of air,
lymph and blood
2. Biochemical
a. Refers to its effect on blood gases and body chemistry
SECONDARY FUNCTIONS OF BREATHING Breathing plays a very important role in non-respiratory functions such as the following:
Self regulation of mental and emotional states
Speech and vocalization
6Copyright 2017 Functional Movement Systems
Multidimensional Model Recent research has exposed that breathing dysfunction is multi-dimensional in nature and includes 3 primary categories of dysfunction: biochemical ( CO2, pH ), biomechanical (patterns, ribcage movement, respiratory muscles), and the psychophysiological dimension. No single test or screening tool can reliably stand alone to identify the client or patient with dysfunctional breathing. Proper evaluation of dysfunctional breathing needs to be comprehensive and consider all 3 key dimensions as well as causes and contributing factors. Single tests can tend to give information about one dimension while overlooking others.
More severe cases of dysfunctional breathing show an overlap of symptoms in each of the 3 domains (see
image below).
Biochemical Dimension The biochemical dimension refers to disturbances in oxygen, carbon dioxide and pH. Hyperventilation is
the most common disturbance in the biochemical dimension. Hyperventilation means breathing in excess
of metabolic requirements with subsequent depletion of CO2. The presence of hyperventilation occurs
when breathing in excess of metabolic requirements leads to the depletion of CO2. People with chronic
hyperventilation can have abnormal breathing control and inaccurate breathing perception. They tend to
abnormally increase rather than decrease ventilation levels when their carbon dioxide levels decrease. This
creates a flywheel effect that perpetuates hyperventilation and hypocapnia. Hyperventilators often feel like
they are not breathing enough even though they are over-breathing which also perpetuates hyperventilation.
One common characteristic of hyperventilators is that instead of controlling breathing, they tend to amplify
the symptoms of hyperventilation and over breathe. This effect can alter an individual’s perception of what is
normal breathing.
8Copyright 2017 Functional Movement Systems
Biomechanical Dimension Breathing Pattern Disorders
1. Thoracic/upper rib cage
2. Excessively irregular breathing
Thoracic Breathing Patterns Characterized by rate volume, rhythm, regularity, timing and dominance
Lower Rib Cage Abdominal
Upper Rib Cage Thoracic
Direction of movement: 1. Normal - Expansion, outwards motion during inhale
2. Paradoxical - Contraction, inwards motion during inhale
Normal Abnormal
THORACIC BREATHING
Supports diaphragm function
Recruited too early
Tension patterns - posterior > anterior (hamstring) Stereotypical Posture of Inhalation Schema
Hyperboloids with rib flaring
Tension at TL Junction
Tension patterns - Anterior > Posterior
1. Reduced ability to dynamically & accurately regulate intra-abdominal pressure
a. Poor motor control
b. Poor spinal support
2. Muscle Imbalance - (neck, shoulder, girdle, abdominals, spine and pelvis)
a. Neck pain
b. Back pain
c. Pelvic pain
11Copyright 2017 Functional Movement Systems
Psychophysiological Dimension It is important to understand that mental and emotional states have a large impact on breathing function and breathing symptoms. The way a person breathes -- both consciously and unconsciously -- can affect the function of the brain and nervous system and mental and emotional states.
The psychophysiological dimension influences ventilatory drive and breathing pattern. It impacts breathing control and can perpetuate dysfunction in the biochemical and biomechanical dimensions.
12Copyright 2017 Functional Movement Systems
Breathing Assessment Basic Principles
For each domain, evaluate at rest and under challenge.
Evaluate breathing in response to and as part of secondary (breathing related function of concern e.g
muscular-skeletal).
Breathing Considerations During a Musculo-Skeletal Exam Breath holding during motor tasks can be a sign of motor control dysfunction
Clients may breath-hold in anticipation of pain or movement and can be a conditioned response that
persists even after pain is gone
Flexion/Extension restrictions in relation to inhalation/exhalation dysfunctions: Someone with an
extension restriction may also have an inhalation restriction. Someone with a flexion restriction may
also have an exhalation restriction
Breathing restrictions/dysfunctions may also cause restrictions in shoulder mobility, dysfunctional
rolling patterns, and balance impairments
Order of Assessment 1. Perform Top Tier SFMA
2. Biochemical Assessment
a. Observation & Testing
b. Breath Holds
3. Biomechanical Assessment
a. Hi-Lo Assessment
b. MARM Assessment
4. Psychophysiological Dimension
a. This is indicated when there are large numbers of symptoms on SEBQ and NQ. Also look for positive
response to questions asking about stress, tension and anxiety in these questionnaires
13Copyright 2017 Functional Movement Systems
Multi-Segmental Flexion
SFMA SCORING
Single-Leg Stance
Multi-Segmental Rotation
Multi-Segmental Extension
Upper Extremity Pattern 1(MRE)
14Copyright 2017 Functional Movement Systems
Name: Date: Total Score: Cervical Flexion Painful Can’t touch Sternum to Chin Excessive effort and/or lack of motor control Cervical Extension Painful Not within 10 degrees of parallel Excessive effort and/or lack of motor control Cervical Rotation Painful Right Painful Left Right Left Nose not in line with mid-clavicle Right Left Excessive effort and/or appreciable asymmetry or lack of motor control Pattern #1 – MRE Painful Right Painful Left Right Left Does not reach inferior angle of scapula Right Left Excessive effort and/or appreciable asymmetry or lack of motor control Pattern #2 – LRF Painful Right Painful Left Right Left Does not reach spine of scapula Right Left Excessive effort and/or appreciable asymmetry or lack of motor control Multi-Segmental Flexion Painful Cannot touch toes Sacral angle <70 degrees Non-uniform spinal curve Lack of posterior weight shift Excessive effort and/or appreciable asymmetry or lack of motor control Multi-Segmental Extension Painful UE does not achieve or maintain 170 ASIS does not clear toes Spine of scapula does not clear heels Non-Uniform spinal curve Excessive effort and/or lack motor control Multi-Segmental Rotation Painful Right Painful Left Right Left Pelvis Rotation <50 degrees Right Left Shoulders rotation <50 degrees Right Left Spine/pelvic deviation Right Left Excessive Knee flexion Right Left Excessive effort and/or lack of symmetry or motor control Single Leg Stance Painful Right Painful Left Right Left Eyes open <10 seconds Right Left Eyes closed < 10 seconds Right Left Loss of Height Right Left Excessive effort or lack of symmetry or motor control Overhead Deep Squat Painful Loss of UE start position Tibia and Torso are not parallel or better Thighs do not break parallel Loss of sagittal plane alignment: Right____ Left _____ Excessive effort, weight shift, or motor control
THE SELECTIVE FUNCTIONAL MOVEMENT ASSESSMENT
15Copyright 2017 Functional Movement Systems
BIOMECHANICAL TESTING 2 stages in testing:
1. Observation
b. Look for hypertonicity in scalenes, SCM, traps, thoracolumbar region
c. Look at movement of shoulders, ribcage, umbilicus in 4 positions
2. Test/measurement
Observation in standing 1. Side on
a. May see forward head, tension in body front vs back
2. Front
a. Signs of hyperactivity in anterior neck, overdeveloped trapezius, dip above clavicle, may see chest
heaving
Assessment of biomechanical dimension in a seated position 1. Observe for muscle hypertonicity and chest or shoulder movement during the breath
2. Can also observe while speaking, looking for gasping, choppy sentences, or speeding up and slowing
down
Behind 1. Look for hypertonicity or over-development of the upper traps
Assessment of biomechanical dimension in a supine position 1. Look for direction of umbilicus movement
2. Look for rib flaring or hollowing out of the stomach (both dysfunctional if present)
3. If you are not sure if this is happening, ask the patient to shallowly breathe gently and slowly into your
hand placed on the stomach to assess for inactivity or hollowing out of the stomach during inhale
Assessment of biomechanical dimension in a prone position 1. Look for direction of umbilicus movement
2. Look for rib flaring or hollowing out of the stomach (both dysfunctional if present)
3. If you are not sure if this is happening, ask the patient to shallowly breathe gently and slowly into your
hand placed on the stomach to assess for inactivity or hollowing out of the stomach during inhale
16Copyright 2017 Functional Movement Systems
Hi-Lo Test This test is performed in the sitting position. The clinician stands or kneels at the front and slightly to the side of
the patient and places one hand on their sternum and one hand on their upper abdomen to determine whether
thoracic or abdominal motion is dominant during breathing. The clinician will demonstrate on themselves
where the palpation points will be, and in the case when a female subject is not comfortable with a male
clinician performing the test, a female clinician will be made available. They will also check for paradoxical
breathing by seeing if the abdomen moves in a direction opposite to the thorax during breathing; this is evident
during inhalation if the abdomen moves toward the spine, and during exhalation, if the abdomen moves in an
outward direction. Test will assess for up to five (5) breath cycles.
Demonstration Assessment
MARM Assessment The Manual Assessment of Respiratory Motion (MARM) was originally developed by Dr. Jan van Dixhoorn. It
is used to assess and quantify breathing patterns, and in particular, the distribution of breathing motion
between the upper and lower parts of the rib cage and abdomen under various conditions. Research has
shown that it is a reliable assessment tool in the hands of trained practitioners (Courtney and Dixhoorn
2009). It does require practice, but once the skills of using this technique and recording findings are acquired,
it is a practical and quick technique.
Hand Position
INSTRUCTIONS
1. Sit behind the subject and place both your hands on the lower lateral rib cage so that your whole hand
rests firmly and comfortably and does not restrict breathing motion.
2. Your thumbs should be approximately parallel to the spine, pointing vertically and your hand
comfortably open with fingers spread so that the little finger approaches a horizontal orientation.
3. Note that the 4th and 5th finger reach below the lower ribs and can feel abdominal expansion.
4. You will make an assessment of the extent of how overall vertical motion of your hands feel relative to
the overall lateral motion.
5. Also decide if the motion is predominantly upper rib cage, lower rib cage/abdomen correlatively
balanced.
Use this information to determine the relative distance from the horizontal line of the upper and lower lines of the MARM diagram. The upper line will be further from the horizontal and closer to the top if there is more vertical and upper ribcage motion. The lower line will be further from the horizontal and closer to the bottom if there is more lateral and lower rib cage/abdomen motion.
6. Finally get a sense of the overall magnitude and freedom of rib cage motion. Place lines further apart to
represent greater overall motion and closer for less motion
18Copyright 2017 Functional Movement Systems
Recording MARM
Draw Upper Line (Line A) Represents upper rib cage and vertical breathing motion
Draw Lower line (Line B) Represents lower rib cage and lateral breathing motion
90 degree line (Line C) This is a reference line only
180
90
0
180
90
0
A
B
C
19Copyright 2017 Functional Movement Systems
The Nijmegen Questionnaire The Nijmegen Questionnaire (NQ) gives a broad view of symptoms associated with dysfunctional breathing
patterns. The Nijmegen Questionnaire was introduced over 30 years ago as a screening tool to detect patients
with hyperventilation complaints who could benefit from breathing training.
Never
0
Rare
1
Sometimes
2
Often
3
Feelings of Anxiety
Scoring the Nijmegen Questionnaire Add all number for a total score. 20 indicates Dysfunctional Breathing.
20Copyright 2017 Functional Movement Systems
The SEBQ The Self Evaluation Breathing Questionnaire (SEBQ) measures a number of different types or qualities of breathing discomfort. It also contains questions about dysfunctional breathing behaviors such as mouth breathing. It was developed by Dr. Rosalba Courtney (Courtney, Greenwood 2009) to represent the broad range of symptoms reported to be found in individual with dysfunctional breathing. Research has shown it to be a reliable instrument for testing and retesting. This makes this questionnaire useful for gauging the effectiveness of breathing training.
The Self Evaluation Breathing Questionnaire 0 1 2 3 I get easily breathless out of proportion to my fitness
I notice myself breathing shallowly
I get short of breath reading and talking
I notice myself sighing
I notice myself yawning
I feel I cannot take a deep or satisfying breath
I notice that I am breathing irregularly
My breathing feels stuck or restricted
My ribcage feels tight and can’t expand
I notice myself breathing quickly
I get breathless when I am anxious
I find myself holding my breath
I feel breathless in association with other physical symptoms
I have trouble coordinating my breathing when speaking
I can’t catch my breath
I feel that the air is stuffy, as if not enough air in the room
I get breathless even when resting
My breath feels like it does not go in all the way
My breath feels like it does not go out all the way
My breathing is heavy
My breathing requires work
My breathing requires effort
I breathe through my mouth at night while I sleep
(0) never/not true at all (1) occasionally/a bit true
Scoring the SEBQ To Score the SEBQ just add the numbers Individuals with scores >= 20 on the Nijmegen on average score >=11 on the SEBQ.
(2) frequently-mostly true (3) very frequently/very true
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Breathing Screen The breathing screen was introduced to help identify if people do/do not have a breathing dysfunction. From internal research, we found that breath hold time and 4-Questions have a sensitivity of .89 for ruling out breathing dysfunction. If you pass the screen, we are 89% sure you don’t have a breathing problem (Kiesel, Rhodes, Mueller, Waninger, Butler, 2016).
BREATH HOLD TIME Breath holding time is shorter in individuals who have increased ventilatory drive or lowered breathlessness thresholds due to psychophysiological, biomechanical or biochemical factors. Short breath holding time can indicate dysfunction in any of these 3 dimensions.
Breath holding time can be tested in 2 ways:
1. After a normal exhale (also know as functional residual capacity)
2. After a full inhale (also known as total lung capacity)
BREATH HOLDING AT FUNCTIONAL RESIDUAL CAPACITY (FRC) FRC refers to the volume of air left in the lungs after a normal, passive exhalation. Breath holding at FRC means holding the breath after a normal relaxed exhalation. Breath holding times help gauge an understanding of all dimensions of breathing because the biomechanical and psychophysiological
dimensions can also affect outcome of breath holding times.
Instructions 1. Have the individual breathe in, breathe out naturally. At the end of the exhale, ask them to hold their
breath by plugging their nose.
2. Tell them to hold their breath until they feel a clear desire to breathe or experience involuntary muscle
activity from the diaphragm or other breathing muscles.
3. Start a timer as soon as the individual holds their breath, and stop when they release their nose or you
see the first sign of muscle activity.
Tips for testing Look for the first sign to breathe. (Normally muscle activity in the stomach or neck)
Interpretation If time is less than 25 seconds, suspect possible dysfunctional breathing
22Copyright 2017 Functional Movement Systems
Breathing Screen BREATH HOLDING AT TOTAL LUNG CAPACITY (TLC) TLC refers to the total volume of air in the lungs at maximal inspiration.
Instructions 1. Have the individual breathe in and then breathe out, then take a deep breath in (maximum inhalation) and hold
their breath by plugging their…
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